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Note: I made a table comparing these three disorders for a course I’m taking, and thought it might be helpful to people, so I decided to post it here. It’s a relatively quick summary and should not be assumed to be 100% accurate. 


  Bipolar Disorder with Psychotic Features Schizoaffective Disorder Schizophrenia
History – Manic-depressive insanity (Kraepelin, 1899)

– Bipolar disorder (1950s)

– 50-75% of patients with bipolar I have >= 1 lifetime episode of psychosis

– Intermediate psychosis (1920s)

– Schizo-affective psychosis

(Kasanin, 1933)

– Dementia praecox (Kraepelin, 1899)

– Schizophrenia (Blueler, 1908)

 

Genetics – Bipolar I has a strong genetic correlation with schizophrenia (68% variance shared) – Fewer large genome wide associated studies (GWAS)

– Has a stronger genetic correlation w/ schizophrenia than bipolar I does

– GWAS have implicated neuronal development and immune function (eg, the complement system)
Demographics – ~ 0.6% of population

– More female (53% F)

– More employment (59%)

– More ever married (50%)

– Onset stressors (66%)

– Substance abuse (41%)

– More SA/SI (59%)

– ~ 0.3% of population

– More male (47% F)

– Middle employment (46%)

– Middle ever married (34%)

– Less onset stressors (55%)

– Substance abuse (33%)

– More SA/SI (57%)

– ~ 1% of population

– 2x more male (34% F)

– Less employment (36%)

– Less ever married (16%)

– Less onset stress (57%)

– Substance abuse (31%)

– Less SA/SI (36%)

Differential diagnosis (DSM5) – Delusions or hallucinations occur exclusively in a manic episode, or in a major depressive episode in a patient with bipolar disorder – >= 2 weeks of psychosis with no mood symptoms

– A manic or major depressive episode occurs during the majority of active phase symptoms

– Active psychotic or prominent residual symptoms usually occur in the absence of a mood episode

 

Time Course – Mood symptoms + associated psychosis relapses and remits

– Patients tend to have relative better insight into their psychosis between episodes

– Psychotic symptoms tend to be more chronic and unremitting

– Superimposed episodes of mania or depression, associated with exacerbation of psychotic symptoms

– Psychotic symptoms tend to be unremitting, with the constant presence of either active symptoms or prominent residual symptoms
Pharmacologic Treatment Acute episode: Antipsychotic + mood stabilizer

Maintenance: Mood stabilizer +/- antipsychotic (which is often tapered after ~ 6 months)

Acute episode: Antipsychotic

Maintenance of bipolar type: Mood stabilizers (eg lithium) +/- antipsychotic

Maintenance of depressive type: Antidepressant +/- antipsychotic

Acute episode: Antipsychotic

Maintenance: Antipsychotic

– Unclear efficacy of lithium augmentation

Prognosis – Historical thought: “manic–depressive disorders recover”

– Current thought: some cases are chronic, but still found to have the best prognosis

 

– Prognosis is intermediate

Harrow et al., 2000 has a nice figure on this

– Historical thought: “schizophrenia ends in dementia”

– Current thought: Some patients can recover (~ 1/3rd), but generally outcomes are worse

More on the genetics:

Wray

Figure from Cross-Disorder Group of the Psychiatric Genomics Consortium et al, 2013; . Nature Genetics (PubMed)

  • SNP-based measurements underestimate total genetic heritability, but allow for good estimates of coheritability between disorders.
  • Of these five disorders, SCZ and BPD have the strongest coheritability, sharing ~68% of their variance.

Charney

Figure from Charney et al., 2017, Translational Psychiatry; part of Figure 4 (PubMed)

  • The relative enrichment of polygenic risk scores for BD (Bipolar Disorder), SCZ, and MDD in patients with BD I, BD II, and schizoaffective disorder, bipolar type (SAB).
  • Schizoaffective patients have more SCZ risk genes than BD I patients do.
  • Schizoaffective patients also have more BD risk genes than BD II patients do.

References

  1. Charney, A. W. et al. Evidence for genetic heterogeneity between clinical subtypes of bipolar disorder. Transl. Psychiatry 7, e993 (2017).
  2. Angst, J. Historical aspects of the dichotomy between manic-depressive disorders and schizophrenia. Schizophr. Res. 57, 5–13 (2002).
  3. Cascade, E., Kalali, A. H. & Buckley, P. Treatment of Schizoaffective Disorder. Psychiatry Edgmont 6, 15–17 (2009).
  4. Harrow, M., Grossman, L. S., Herbener, E. S. & Davies, E. W. Ten-year outcome: patients with schizoaffective disorders, schizophrenia, affective disorders and mood-incongruent psychotic symptoms. Br. J. Psychiatry J. Ment. Sci. 177, 421–426 (2000).
  5. Cross-Disorder Group of the Psychiatric Genomics Consortium et al. Genetic relationship between five psychiatric disorders estimated from genome-wide SNPs. Nat. Genet. 45, 984–994 (2013).
  6. Leucht, S., Helfer, B., Dold, M., Kissling, W. & McGrath, J. J. Lithium for schizophrenia. Cochrane Database Syst. Rev. CD003834 (2015). doi:10.1002/14651858.CD003834.pub3
  7. Sekar, A. et al. Schizophrenia risk from complex variation of complement component 4. Nature 530, 177–183 (2016).
  8. Baethge, C. et al. Hallucinations in bipolar disorder: characteristics and comparison to unipolar depression and schizophrenia. Bipolar Disord. 7, 136–145 (2005).
  9. Harrison, G. et al. Recovery from psychotic illness: a 15- and 25-year international follow-up study. Br. J. Psychiatry J. Ment. Sci. 178, 506–517 (2001).=
  10. Tondo, L. et al. Comparison of psychotic bipolar disorder, schizoaffective disorder, and schizophrenia: an international, multisite study. Acta Psychiatr. Scand. 133, 34–43 (2016).
  11. Yen, C.-F. et al. Relationships between insight and medication adherence in outpatients with schizophrenia and bipolar disorder: prospective study. Psychiatry Clin. Neurosci. 59, 403–409 (2005).
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In the past 20 years, deep brain stimulation (DBS) has been used for over 100,000 patients with Parkinson’s disease. The success of this procedure has led investigators to try DBS for other neurologic conditions, such as Alzheimer’s disease (AD).

In 2016, Lozano et al reported on one of the largest trials for DBS in AD, the “ADvance” trial, in which they targeted the fornix, a bundle of nerve fibers in the center of the brain that is the major output tract of the hippocampus.

250px-Gray747

This was a well-run, double-blind, randomized study. One of the nice aspects about brain stimulation trials is the ease of performing a sham stimulation arm. That is, treatment can be randomly turned either “on” and “off” for a period of time, allowing a subset of participants to serve as controls (stimulation turned “off”) for a period of time before they actually do get the stimulation (stimulation turned “on”) in case it is actually helpful.

In terms of the trial results, one of the patients (out of 42) had an implant infection. Overall, the trial did not show a significant benefit mitigating the decline in ADAS-13 or CDR-SB scores (measures of cognitive function):

Screen Shot 2017-11-24 at 8.11.30 AM

Lozano et al 2016; doi: 10.3233/JAD-160017

While this trial did not show efficacy at their sample sizes, personally I expect that DBS for early AD could work to at least alleviate symptoms, if the right circuits were targeted at the right time.

My reasoning here is that we know that a few other cognitive strategies can help slow the course of AD, including processing speed training and acetylcholinesterase inhibitors.

There are at least 4 active DBS trials for AD on clinicaltrials.gov:

It will be interesting to monitor this growing field in the coming years.

Microglia can last a lifetime

An important paper from Füger et al last month, in which they labelled individual microglia in mouse brains and tracked their locations over 1.5 years. Here were some of their major findings:

  • The median lifespan of microglia was estimated to be approximately 2.5 years, which is close to the mean lifespan of the mice that they were studying. So, it is fair to think of microglia as long-lived tissue macrophages. It is also clear how changes in microglia epigenetics in earlier life could affect late-life cognitive outcomes.
  • Microglia died at a higher rate in older mice, suggesting that aging may lead to alterations in microglia function that could affect neurodegenerative disease.
  • In APPPS1 mice, microglia proliferate 3x more than usual in areas of the cortex without amyloid plaque, but only proliferate a normal amount in areas of the cortex with amyloid plaque. This suggests that any increase in microglia near plaque is likely due to migration, not local proliferation.

An interesting study from Risacher et al splits ADNI participants into three subtypes of Alzheimer’s, based on whether their baseline atrophy was more severe in the hippocampus and/or cortex. These groups were previously defined based on where in the brain pathologic tau deposits are predominant on postmortem exam, but the authors adapted them to the MRI level. Here were their definitions:

  • Hippocampal sparing (HpSpMRI) = Hippocampal volume:Cortical volume ratio > 75th percentile, Hippocampal volume > median, Cortical volume < median. (n = 33)
  • Limbic predominant (LPMRI) = Hippocampal volume:Cortical volume ratio < 25th percentile, Hippocampal volume < median, Cortical volume > median.  (n = 38)
  • Typical AD (tADMRI) = all other participants (n = 158)

For participants who had 24 month longitudinal data, they found that the hippocampal sparing subtype had the worst progression of cognitive decline, despite a similar baseline cognition profile:

Screen Shot 2017-11-01 at 5.10.21 AM

Figure 2C from PMID: 29070667

 

We know that many traumatic brain injuries (TBIs) can be devastating. An important research topic is predicting what the effect a TBI of a particular type and severity will have on neuropathology and behavior.

Neuropathology is relatively easier to measure, but it is still hard to tell causality because a lot of the “markers” of TBI seen on neuropathologic exam are also sometimes seen in individuals who never had a TBI. Although their degree or distribution might be different.

Behavioral effects of TBI are especially hard to measure because you need standardized measures across time in both TBI-affected and TBI-unaffected individuals, controlling for all of the other factors that are known to affect behavior. A tough nut to crack.

Shively et al. recently described their clever study to address the causality of neuropathologic changes in TBI.

They compared the postmortem brains from donors with schizophrenia treated with prefrontal leucotomy (n = 5; more than 40 years prior to death) to age-matched donors with schizophrenia who hadn’t undergone leuctomy (n = 5).

Leucotomy, an obsolete treatment for schizophrenia, involved traumatic interruptions of white matter axons in the prefrontal cortex via burr holes. Here is what the lesions look like on MRI:

Screen Shot 2017-09-21 at 2.20.08 PM

From Uchino et al., an MRI of a person with a history of prefrontal leucotomy shows bilateral frontal white matter lesions; PMID:11156773

These authors looked at cortical tissue slices cut in the coronal plane at the leucotomy site, as well as slices rostral and caudal to the site.

Screen Shot 2017-09-21 at 2.24.16 PM

Shively et al.; PMC5325841

Here were some of their findings:

  • They found phosphorylated tau in neurons and astrocytes in cortex adjacent to the leucotomy site in 5/5 of the donors treated with leucotomy, but not in the rostral/caudal sites or in the donors who did not have leucotomy.
  • The p-tau tended to be at sulcal depths or surrounding small blood vessels. This is similar to what is seen in CTE.
  • They also found amyloid beta depositions in the cortex near the leucotomy sites, but only in the 3/5 donors who had at least one APOE ε4 allele.

Overall, this is really nice study that allows us to see the effect of TBI-associated axon injury in humans in a precisely controlled manner. What we see is that it causes phosphorylated tau accumulations in a similar distribution to that of CTE.

One of the exciting alternatives to the amyloid immunotherapies in clinical trials for Alzheimer’s disease (AD) are anti-tau antibodies.

There are several of these drugs in earlier stages of development, although none that I know of in phase 3. To take two concrete examples, let’s focus in on BioGen’s two anti-tau immunotherapies:

  • BMS-986168/BIIB092 = an humanized IgG4 monoclonal antibody targeting extracellular tau
  • BIIB076 = a monoclonal antibody against both monomeric and fibrillar tau

Both of these drugs are also being tested in PSP, which is a relatively rare, classical familial tauopathy in a way that AD isn’t — because in PSP, the 1-5% of familial cases are known to be caused by certain MAPT mutations. Whereas I don’t know of well-validated genetic mutations in MAPT that are associated with increased risk of Alzheimer’s, except for some preliminary reports of small statistical associations, such as this one.

To try to force myself to be accountable and quantitative, what is my prediction for the probability that each of these two drugs will be approved by the FDA by the end of 2025? Same rules and disclosures as my previous post about this, but two years extended because these drugs are in earlier stages of development.

I’m going with 2.5% for BIIB092 (in phase II) and 1.5% for BIIB076 (still in phase I). Clearly abnormalities in tau proteins are highly associated with pathogenesis in AD, indeed more strongly associated than Aβ, and there have been a number of suggestions that the tau abnormalities are causal.

But in my opinion, we don’t know for sure yet that these tau abnormalities are truly causal, and that stopping tau aggregation will be helpful.

On one hand, if an anti-tau antibody works, why shouldn’t an anti-NFL antibody, or any of the other proteins that are markers of axonal damage in AD and are inversely associated with cognitive status? Maybe they all would, but this thought experiment is a bit troubling to me.

On the other hand, anti-tau antibodies have already been shown to be helpful in an APP-overexpressing AD mouse model, improving both cognitive function and the proportion of mushroom dendritic spines.

Screen Shot 2017-09-20 at 7.36.40 AM

Castillo-Carranza et al 2015 Fig 1D; TOMA = anti-tau oligomer-specific monoclonal antibody, Tg2576 = APP-overexpressing AD mutant mouse; http://www.jneurosci.org/content/35/12/4857.long

It is asking a lot, but I would be more confident about the clinical relevance of this type of mouse study if it were shown that immunotherapies against other protein markers of axon damage, such as anti-NFL antibodies, were not successful in ameliorating cognitive decline, as a negative control.

Certainly I will be rooting for these anti-tau drugs to be successful in clinical trials and I think they make a lot of sense, but like most AD drugs in development, my prediction is that they are a long shot.

Idiopathic normal pressure hydrocephaus (NPH) is a diagnosis of occult hydrocephalus with normal CSF pressure on LP that was first described in 1965 and is often considered one of the treatable causes of dementia.

The original paper used the now uncommon brain imaging technique of pneumoencephalography, which involved draining the CSF, injecting air as a contrast medium, and performing a brain xray:

Screen Shot 2017-09-17 at 10.48.34 AM

Figure 2 from Adams et al 1965 showing uniformly enlarged ventricles; doi: 10.1056/NEJM196507152730301

At my med school we learned NPH by the triad of “wet, wobbly, and wacky”, referring to its classic triad of symptoms: urinary incontinence, gait disturbance, and cognitive impairment.

Like many symptom triads, these symptoms are non-sensitive, with the full triad seen in <60% of patients. It is also non-specific, as urinary incontinence is seen in ~20-40% of those over 60, gait impairment is seen in ~20% over those over 75, and mild cognitive impairment is seen in ~35% of those over 70.

Espay et al explain all of this in the introduction of their critical literature review of idiopathic NPH. One of their major points is that ventricle enlargement is also non-specific, as it is common in other neurodegenerative diseases such as AD, DLB, and PSP.

Here are some of their other points:

  • There are no specific clinical, imaging, or neuropathologic findings in NPH.
  • The determination of ventricle enlargement on MRI is subjective and not standardized.
  • A “true” diagnosis is dependent upon a treatment response to CSF diversion via a ventriculoperitoneal shunt (VPS), which is circular and problematic.
  •  There has never been a well-defined RCT to evaluate the use of VPS in NPH.
  • Because many patients diagnosed with NPH may in fact have NPH that is secondary rather than a precursor to other neurodegenerative diseases, the fact that VPS may lead to short-term cognitive amelioration even in these patients suggests that VPS should still be considered as a way to improve cognition even in patients that are diagnosed with these neurodegenerative diseases.

Overall, this paper is well worth a read for people interested in treatments for dementia.